PT’s, OT’s Looking for Ways to Improve Head Control

GUEST BLOGGER: Kathryn Biel.

Patricia submitted this question:

So how do you improve head control? I have tried several courses and have left with no real answer to this question. Do you have any ideas?

Head control is a tricky thing. It is the result of the interplay of the vestibular system, the visual system, motor control, strength, muscle tone, and endurance. In theory, it is one of the first things to develop. Head control is developed through prone. The vestibular and visual systems are critical in developing the desire to lift the head and push up onto prone prop and eventually on to extended arms. At this point, the eyes develop convergence and divergence, and the Symmetrical Tonic Neck Reflex is used to assist in getting the child into quadruped.

I’m guessing that your patient is beyond this infant stage. Depending on the age of the patient, as well as the presence of co-morbidities, may impact your treatment strategies. A thorough visual assessment (by Developmental or Behavioral Optometry) is necessary to determine if the Visual Righting and the Vestibulo-Ocular Reflexes are intact. These are a major driving force in providing the motivation to lift the head to midline in the first place. Cortical visual impairments and visual field cuts can often result in a person holding their head out of midline, as that is how functional vision is accessed. It is important to determine where the functional visual field is so that you are not asking a person to function where he or she cannot see.

For strength development, go back to prone. Development of the back and neck extensors, as well as shoulder girdle strengthening, is critical in possessing head control in the upright position. If extensor control is not present to counter balance flexor strength (which is developed in supine), then functional midline co-contraction will not be realistic.

In terms of sitting, in order to gain head control, you must first tackle the pelvis. Trying for head control without a well-seated pelvis is like building a house from the roof down. The pelvis must be supported and neutral. Assuming that the patient you are looking to develop head control in is multiply impaired, in addition to controlling the pelvis, you are looking to fully support the trunk as well. This includes adaptive seating that supports the trunk laterally, and helps to correct any curves (forward/back as well as lateral). The feet and legs should be well supported to further provide a stable base of support. Remember, if you are asking a person to work on head control, then that is what they are working on. It does not include working on trunk control.

Over the past few years, I’ve used a few different trunk supports on wheelchairs that have helped to improve upper trunk and scapular position. These include the Stealth I2I head and neck support system and the use of two AEL Y-shaped trunk supports (one on each side). In the past, I’ve also used the Headmaster collar to work on very small range head control (lifting from the resting position on the collar to fully upright).

I would love to hear what other therapists are doing to work on head control. Please let me know, and Patricia, I hope this helps!

8 Responses to PT’s, OT’s Looking for Ways to Improve Head Control

How about head control in a 4 month old who is blind, responds inconsistently to sound, has hydrocephalus, and will be receiving a plagiocephaly helmet next week that needs to be worn 23 hours a day? That is my latest challenge and I need ideas.

We do a lot with BWSS and suspension toys at our clinic. We actually put helmets on kids when they are in a body weight support surrounded by a grid and attach bungees to the helmet to assist in holding the head in midline. Also, as a simpler approach if you don’t have a BWSS grid, I would suggest prone over a wedge, then hang bells, chimes, etc. above the child’s head that he would activate when he lifts the head up. You could gradually raise the bells a bit higher to hopefully eventually get to 70 + degrees of neck extension. Good Luck!

I agreed with Kathryn’s idea, i.e. go back to prone and try to facilitate the head extension in that position. if the client is spending a long time in sitting position, try to use either anterior tilt or posterior tilt ( it is not conflict of each other)to facilitate the desired head/neck extension. Depending on the child’s reaction, some benefit from anterior tilting , while the other is doing better with posterior tilt. We have few students developed head control at age 20 after utilizing the i2i with chin prompt.It is like the PRE, allowing them to work on those head extensors muscle in a small range first before over stretching them.
An upper extremity supporting surface (Tray)can be helpful if the child can use upper extremities to push their upper thoracic region which can also enhance the head/neck extension.
hope this help!

I would try for short bouts of strengthening activities and a high frequency throughout the day. Try different pitched noises, the kiddo may respond more to one tone or another. Also try using a toy with some vibration placing it on the shoulders when he/she is prone. You may get some extension and rotation that way. The helmet for plagiocephaly likely won’t impact his/her head control too much, depending on the weight. Different products weigh less than others. I would reach out to the treating therapist or orthotist who is fitting this baby with the device to work out a treatment plan that allows for optimal change in the product as well as optimal strength and development from your sessions.

It can be tricky working on prone and head control with a visually impaired infant. First of all, if there is a TVI (teacher of children with visioni impairments) working wiht the baby/family, I would try to schedule co-treatments and/or consults. They can be a great resource for identifying activities and materials to engage the baby in active play. With regards to head control, I would start working in prone by having the baby in a chest to chest position with the parent(s). Have the parent lie down in a semi-reclined position. Place the baby chest to chest with the parent and have the parent. You can have the parent help to position the baby’s arms into a prop on forearms position. The parent can also provide some gentle pressure to the baby’s bottom to help shift the center of gravity to encourage head elevation. In this position the baby may elevate his/her head in reponse to parent’s voice or even in response to vibration when parent is speaking. You can also try an inclined prone position over a large therapy ball or propped on the floor. If you use a therapy ball, just be sure to provide lots of physical contact/support to the baby as this can be a scary and disorienting position for a visually impaired baby. I love working with visually impaired kiddos! Looking down the road a bit, I have found that visually immpaired children like to roll or scoot on buttocks for mobility, but don’t give up on quadruped or crawling. I have had many blind students crawl and it is so important for decreasing tactile sensitivity in the hands and for upper body stability/control for Braille reading/writing and for cane use for mobility. Good luck and hope this helps!

I would do prone as well but it needs to be in a more anti gravity position so they don’t have to work so hard especially with the double disadvantage of hydrocephalous and helmet. Get them on a wedge. You can prop a couch cushion up so it is at a 30 or 40 degree angle. My favorite place to work on head control is an exercise ball. It allows for easy weight shifting and you can put them at whatever angle you want to make left their head movement more easy. I love the idea of vibrating toys. Don’t know if they respond to the parents voice. That is something I use often. What ever noise toy your using make sure you touch them with it either on their face or hand so they become aware of it.

I too am working with a 17 month old with cortical blindness and hydrocephalus. I appreciate all the above treatment ideas. The question I have is what functional skill do you use in writing a goal of head control for a child like this? I would typically use something like “the child will demonstrate improved head control…. in order to view and interact with their environment/with caregiver etc. I’m not sure what to say for a child who is blind. Any suggestions are appreciated!